[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                       DATA FOR DECISION-MAKING:
                     RESPONSIBLE MANAGEMENT OF DATA
                       DURING COVID	19 AND BEYOND

=======================================================================

                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON INVESTIGATIONS
                             AND OVERSIGHT

                                 OF THE

                      COMMITTEE ON SCIENCE, SPACE,
                             AND TECHNOLOGY
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           SEPTEMBER 23, 2020

                               __________

                           Serial No. 116-82

                               __________

 Printed for the use of the Committee on Science, Space, and Technology
 
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


       Available via the World Wide Web: http://science.house.gov
       
                              __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
41-411PDF                  WASHINGTON : 2021                     
          
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              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

             HON. EDDIE BERNICE JOHNSON, Texas, Chairwoman
ZOE LOFGREN, California              FRANK D. LUCAS, Oklahoma, 
DANIEL LIPINSKI, Illinois                Ranking Member
SUZANNE BONAMICI, Oregon             MO BROOKS, Alabama
AMI BERA, California,                BILL POSEY, Florida
    Vice Chair                       RANDY WEBER, Texas
LIZZIE FLETCHER, Texas               BRIAN BABIN, Texas
HALEY STEVENS, Michigan              ANDY BIGGS, Arizona
KENDRA HORN, Oklahoma                ROGER MARSHALL, Kansas
MIKIE SHERRILL, New Jersey           RALPH NORMAN, South Carolina
BRAD SHERMAN, California             MICHAEL CLOUD, Texas
STEVE COHEN, Tennessee               TROY BALDERSON, Ohio
JERRY McNERNEY, California           PETE OLSON, Texas
ED PERLMUTTER, Colorado              ANTHONY GONZALEZ, Ohio
PAUL TONKO, New York                 MICHAEL WALTZ, Florida
BILL FOSTER, Illinois                JIM BAIRD, Indiana
DON BEYER, Virginia                  FRANCIS ROONEY, Florida
CHARLIE CRIST, Florida               GREGORY F. MURPHY, North Carolina
SEAN CASTEN, Illinois                MIKE GARCIA, California
BEN McADAMS, Utah                    THOMAS P. TIFFANY, Wisconsin
JENNIFER WEXTON, Virginia
CONOR LAMB, Pennsylvania
                                 ------                                

              Subcommittee on Investigations and Oversight

                  HON. BILL FOSTER, Illinois, Chairman
SUZANNE BONAMICI, Oregon             RALPH NORMAN, South Carolina, 
STEVE COHEN, Tennessee                   Ranking Member
DON BEYER, Virginia                  ANDY BIGGS, Arizona
JENNIFER WEXTON, Virginia            MICHAEL WALTZ, Florida
                         
                         
                         C  O  N  T  E  N  T  S

                           September 23, 2020

                                                                   Page

Hearing Charter..................................................     2

                           Opening Statements

Statement by Representative Bill Foster, Chairman, Subcommittee 
  on Investigations and Oversight, Committee on Science, Space, 
  and Technology, U.S. House of Representatives..................     8
    Written Statement............................................     9

Statement by Representative Ralph Norman, Ranking Member, 
  Subcommittee on Investigations and Oversight, Committee on 
  Science, Space, and Technology, U.S. House of Representatives..    10
    Written Statement............................................    11

Written statement by Representative Eddie Bernice Johnson, 
  Chairwoman, Committee on Science, Space, and Technology, U.S. 
  House of Representatives.......................................    12

                               Witnesses:

Dr. Lisa M. Lee, Ph,D., Associate Vice President for Research and 
  Innovation, Virginia Tech
    Oral Statement...............................................    14
    Written Statement............................................    16

Dr. Lisa L. Maragakis, MD, MPH, Senior Director of Infection 
  Prevention, Johns Hopkins Health System
    Oral Statement...............................................    24
    Written Statement............................................    26

Mr. Avik Roy, President, Foundation for Research on Equal 
  Opportunity
    Oral Statement...............................................    29
    Written Statement............................................    31

Ms. Janet Hamilton, MPH, Executive Director, Council of State and 
  Territorial Epidemiologists
    Oral Statement...............................................    43
    Written Statement............................................    45

Discussion.......................................................    61

              Appendix: Additional Material for the Record

Letter submitted by the Premier Inc. healthcare alliance.........    74

 
                       DATA FOR DECISION-MAKING:
                     RESPONSIBLE MANAGEMENT OF DATA
                       DURING COVID-19 AND BEYOND

                              ----------                              


                     WEDNESDAY, SEPTEMBER 23, 2020

                  House of Representatives,
      Subcommittee on Investigations and Oversight,
               Committee on Science, Space, and Technology,
                                                   Washington, D.C.

     The Subcommittee met, pursuant to notice, at 11:03 a.m., 
via Webex, Hon. Bill Foster [Chairman of the Subcommittee] 
presiding.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

     Chairman Foster. The hearing will now come to order. 
Without objection, the Chair is authorized to declare recess at 
any time.
     Before I deliver my opening remarks, I wanted to note 
that, pursuant to House Resolution 965, today, the 
Subcommittees are meeting virtually. I want to announce a 
couple of reminders to the Members about conduct of this remote 
hearing. First, Members should keep their video feed on as long 
as they are present in the hearing. Second, Members are 
responsible for muting and unmuting their own microphones, so 
please keep your microphones muted unless you're speaking. And 
finally, if Members have documents that they wish to submit for 
the record, please email them to the Committee Clerk, whose 
email address was circulated prior to the hearing.
     Well, good morning, and welcome to this virtual hearing on 
the Subcommittee of Investigations and Oversight of the House 
Science Committee. Today's hearing focuses on how data drives 
the decisionmaking at every level of response to COVID-19. 
Ensuring the integrity, transparency, and accuracy of this 
data, free from political interference, is crucial to keeping 
us safe and prepared. Accurate data is crucial to policy 
planners, to first responders and medical professionals, to 
epidemiologists and scientific researchers, to politicians, and 
to the general public. The American public should never have to 
doubt that Federal data collection and management efforts serve 
one purpose alone: informing public health decisions with the 
best available science.
     COVID-19 has presented an unparalleled challenge to our 
Nation's public health infrastructure. Epidemiologists, 
hospital administrators, and government data scientists have 
worked tirelessly to adapt existing systems for the ever-
evolving landscape. With the CDC's (Centers for Disease Control 
and Prevention's) National Health Safety Network's (NHSN's) 
COVID-19 module, which was launched in late March, an existing 
system was expanded to meet an urgent need at the peak of the 
initial COVID-19 crisis. Experienced CDC surveillance 
scientists collected, cleaned, and analyzed emerging data to 
produce region-specific reports on COVID-19 and published these 
reports publicly on the CDC website. Local and State health 
authorities, as well as hospitals and infectious disease 
modelers, were able to use these reports to gauge the severity 
of the crisis in their region and make decisions on resource 
management and disease control measures, and coordinating this 
with nearby cities and States. While it was not a perfect 
system--NSHN was reportedly overstretched and under-resourced 
for this huge task--hospitals had the benefit of working with 
CDC epidemiologists that they had cultivated relationships with 
over the years.
     In April, with minimal if any consultation with Congress, 
HHS (Department of Health and Human Services) contracted with 
TeleTracking Technologies to institute a totally new system. 
This system would be entirely dedicated to the management of 
COVID-19 data. In July, reporting to the new system became 
mandatory. There is much to be said about the burden that this 
switch placed on hospitals, and our witnesses are--today are 
well-equipped to answer our questions about the effects of this 
transition over the past two months.
     But beyond implementation issues, this switch away from 
the CDC has called into question the role of career scientists 
in overseeing the data quality of the TeleTracking system. The 
stakes could not be higher because it's so important that 
public trust in the COVID-19 data underlying public health 
decisions means so much to our country. Moving the Federal 
Government's primary data base from the CDC with its expert 
career epidemiologists to an HHS now dominated by short-term 
political appointees places this all-important data at risk of 
political manipulation.
     And, unfortunately, concerns about political manipulation 
of COVID-19 information are not unfounded. We have repeatedly 
seen public attacks against CDC scientists for the sake of 
bolstering the President's questionable claim that he has 
successfully controlled the virus. Just this month, it was 
reported that HHS political officials have attempted to edit, 
delay, and prevent the publication of the CDC's Morbidity and 
Mortality Weekly Reports. Only under a cynical Administration 
hostile to science could these CDC analytical reports be 
considered ``hit pieces'' aimed at undermining the President 
unless somehow they see scientific truth as the enemy.
     Now, there will always be a pressure to misreport public 
health information. This can come from top down from 
politicians at all levels who might benefit politically from 
misrepresenting to the public their success at controlling 
infectious diseases. It can come from industries, facilities, 
or groups who stand to benefit financially from misleading the 
public, or from the bottom up, from doctors, clinics, 
hospitals, or nursing homes that have an incentive to minimize 
public disclosure of the extent of spread of infectious 
diseases at their patient care facilities. And there are 
legitimate gray areas and a need for clear and consistent 
reporting standards such as differing standards for 
hospitalization, standards for reporting racial and ethnic 
information, or the reporting of the simple cause of death for 
patients with significant comorbidities.
     As the pandemic continues to spread, we must ensure that 
COVID-19 data is protected from inappropriate influence and is 
transparent, accessible, and accurate. Unfortunately, we have 
seen firsthand the dangers and the cost to human lives of 
incorrect information being passed to decisionmakers when 
Governors, Mayors, hospitals, and local health officials were 
told to make plans based on faulty projections of the 
availability of testing, or PPE (personal protective 
equipment), or of sanitizer. Those plans inevitably fail, and 
tens of thousands of Americans died.
     As a Member of the Select Subcommittee on the Coronavirus 
Crisis, and as Chairman of this Subcommittee, I'm committed to 
ensuring that decisionmakers at all levels across the United 
States have access to reliable data unmarred by political 
influence.
     So I look forward to today's hearing, hearing from our 
witnesses about how we can best invest public health--in public 
health infrastructure and disease surveillance that can serve 
us through this pandemic and beyond.
     [The prepared statement of Chairman Foster follows:]

    Good morning, and welcome to this virtual hearing of the 
Subcommittee on Investigations and Oversight. Today's hearing 
focuses on how data drives the decision-making at every level 
of the response to COVID-19. Ensuring the integrity, 
transparency, and accuracy of this data, free from political 
influence, is crucial to keeping us safe and prepared. The 
American public should never doubt that Federal data collection 
and management efforts serve one purpose alone: informing 
public health decisions with the best available science.
    COVID-19 has presented an unparalleled challenge to our 
nation's public health infrastructure. Epidemiologists, 
hospital administrators, and government data scientists have 
worked tirelessly to adapt existing systems for the ever-
evolving landscape. With the CDC's National Healthcare Safety 
Network's COVID-19 module, launched in late March, an existing 
system was expanded to meet an urgent need at the peak of the 
initial COVID-19 crisis. Experienced CDC surveillance 
scientists collected, cleaned, and analyzed emerging data to 
produce region-specific reports on COVID-19, and published the 
reports publicly on the CDC website. Local and state health 
authorities, as well as hospitals and infectious disease 
modelers, were able to use these reports to gauge the severity 
of the crisis in their region and make decisions on resource 
management, and disease control measures, and coordinating with 
nearby cities and states. While it was not a perfect system--
NSHN was reportedly overstretched and under-resourced for this 
huge task--hospitals had the benefit of working with CDC 
epidemiologists they had cultivated a relationship with for 
years.
    In April, HHS contracted with TeleTracking Technologies to 
institute a totally new system. This system would be entirely 
dedicated to the management of COVID-19 data. In July, 
reporting to the new system became mandatory. There is much to 
be said about the burden this switch placed on hospitals, and 
our witnesses today are well equipped to answer our questions 
about the effects of this transition over the past two months. 
Beyond implementation issues, this switch away from CDC has 
called into question the role of career scientists in the 
TeleTracking system. The stakes could not be higher, because it 
is so important that the public trust the COVID-19 data 
underlying public health decisions. Moving the Federal 
government's primary database from CDC--and its expert 
epidemiologists--to HHS places this all-important data at risk 
of political manipulation.
    Unfortunately, concerns about political manipulation of 
COVID-19 information are not unfounded. We have repeatedly seen 
attacks against CDC scientists for the sake of bolstering the 
President's claim that he has successfully controlled the 
virus. Just this month, it was reported that HHS political 
officials have attempted to edit, delay, and prevent the 
publication of the CDC's Morbidity and Mortality Weekly 
Reports. Only under a cynical administration hostile to science 
could these CDC reports be considered ``hit pieces'' aimed at 
undermining the President.
    There will always be political pressure to mis-report 
public health information, whether from politicians themselves 
or from industries or groups who stand to benefit from 
misleading the public about the risk posed to their bottom line 
or political message. As the pandemic continues to spread, we 
must ensure that COVID-19 data is protected from inappropriate 
influence and is transparent, accessible, and accurate. As a 
Member of the Select Subcommittee on the Coronavirus Crisis, 
and as Chairman of this Subcommittee, I am committed to 
ensuring that decision-makers at all levels, across the United 
States, have access to reliable data unmarred by political 
influence. I look forward to hearing from our witnesses today 
about how we can best invest in public health infrastructure 
and disease surveillance that can serve us through this 
pandemic and beyond.

     Chairman Foster. And the Chair will now recognize the 
Ranking Member of the Subcommittee on Investigations and 
Oversight, Mr. Norman, for an opening statement.
     Mr. Norman. Good morning and thank you, Chairman Foster. 
And I want to thank the witnesses for your participation today. 
I hope we can use this hearing as an opportunity not only to 
identify where data gaps exist, but also to identify potential 
solutions to help us all better understand the ongoing 
coronavirus pandemic and make well-informed decisions moving 
forward.
     Over the past several months, we've seen life as we know 
it change within the blink of an eye. Cities across the country 
went into shut down, schools and nonessential businesses were 
closed, and stay-at-home orders were issued to limit the spread 
of the virus. We saw our economy come to a halt as millions of 
Americans lost their jobs and many businesses were forced to 
permanently shut their doors.
     On a daily basis, health officials, healthcare providers, 
policymakers, and other leaders across the country have had to 
make difficult decisions about the health and safety of their 
communities. Decision-makers should rely on detailed and 
accurate data to advise and prioritize response efforts. Data 
issues are not a new public health problem, as data collection, 
management, and sharing have challenged the public health 
community since long before the coronavirus pandemic.
     Unfortunately, the coronavirus pandemic increased the 
strain on public health infrastructure all across our country. 
Incomplete and at times inaccurate data is being reported to 
State and local health departments, which is then used to 
inform critical policy and operational decisions. The 
catastrophic impact the coronavirus has had on long-term 
facilities and nursing homes is just one example of how poor 
data management has led to detrimental consequences over the 
past few months. If better data had been available to 
policymakers, we would have known just how vulnerable the 
elderly are to this virus, and the countless deaths and 
hospitalizations could have been prevented.
     One of the biggest data challenges affecting the 
coronavirus pandemic is that we do not know exactly how much of 
it is out there, and researchers must estimate its prevalence 
through data-driven disease forecasting and modeling. 
Predictions on the number of coronavirus cases, 
hospitalizations, and deaths help inform public decisionmaking 
by calculating the expected impact of the pandemic in coming 
weeks or even months.
     Outdated public health systems are in desperate need of 
modernization. Currently, the virus is spreading faster than 
public health data and response efforts. This has been allowed 
due to a lack of integrating public health systems all across 
the State and local governments. We must consider how to 
incorporate new and innovative techniques to improve slow and 
static decisionmaking processes and this begins with 
modernization of our public health infrastructure.
     We cannot afford to make bad policy decisions due to poor 
data during this pandemic and future public health emergencies. 
It is important we understand the gaps and challenges with the 
data that we have to best inform response efforts.
     As policymakers, our decisions must be informed by data. 
The quality of those decisions is directly affected by the 
quality of the data we're using. I look forward to hearing more 
about how we can improve the timeliness, accuracy, and 
distribution of public health data.
     I yield back.
     [The prepared statement of Mr. Norman follows:]

    Good Morning and thank you, Chairman Foster. And thank you 
to the witnesses for your participation today. I hope we can 
use this hearing as an opportunity not only to identify where 
data gaps exist, but also to identify potential solutions to 
help us all better understand the ongoing Coronavirus pandemic 
and make well-informed decisions moving forward.
    Over the past several months, we've seen life as we know it 
change within the blink of an eye. Cities across the country 
went into shut down, schools and non-essential businesses were 
closed, and stay-at-home orders were issued to limit the spread 
of the virus. We saw our economy come to a halt as millions of 
Americans lost their jobs and many businesses were forced to 
permanently shut their doors.
    On a daily basis, public health officials, healthcare 
providers, policymakers, and other local leaders across the 
country have had to make difficult decisions about the health 
and safety of their communities. Decision makers should rely on 
detailed and accurate data to advise and prioritize response 
efforts. Data issues are not a new public health problem, as 
data collection, management, and sharing have challenged the 
public health community since long before the Coronavirus 
pandemic.
    Unfortunately, the Coronavirus pandemic increased the 
strain on public health infrastructure across the country. 
Incomplete and at times inaccurate data is being reported to 
state and local health departments, which is then used to 
inform critical policy and operational decisions.
    The catastrophic impact the Coronavirus has had on long-
term care facilities and nursing homes is just one example of 
how poor data management has led to detrimental consequences 
over the past few months. If better data had been available to 
policymakers, we would have known just how vulnerable the 
elderly are to this virus, and countless deaths and 
hospitalizations could have been prevented.
    One of the biggest data challenges affecting the 
Coronavirus pandemic is that we do not know exactly how much of 
it is out there, and researchers must estimate its prevalence 
through data-driven disease forecasting and modeling. 
Predictions on the number of Coronavirus cases, 
hospitalizations, and deaths help inform public health 
decision-making by calculating the expected impact of the 
pandemic in coming weeks or even months.
    Outdated public health systems are in desperate need of 
modernization. Currently, the virus is spreading faster than 
public health data and response efforts. This has all been 
allowed due to a lack of integrating public health systems 
across state and local governments. We must consider how to 
incorporate new and innovative techniques to improve slow and 
static decision-making processes amid this pandemic, and this 
begins with modernizing public health infrastructure.
    We cannot afford to make bad policy decisions due to poor 
data during this pandemic and future public health emergencies. 
It is important that we understand the gaps and challenges with 
the data that we have to best inform response efforts.
    As policymakers, our decisions must be informed by data. 
The quality of those decisions is directly affected by the 
quality of the data we're using. I look forward to hearing more 
about how we can improve the timeliness, accuracy, and 
distribution of public health data.
    I yield back.

     [The prepared statement of Chairwoman Eddie Bernice 
Johnson follows:]

    Thank you, Chairman Foster, and thank you to our panel of 
witnesses for appearing before the Subcommittee today. The 
COVID-19 pandemic has claimed 200,000 lives in the United 
States. In my home state of Texas, there have been over 28,000 
new cases reported in the past week alone. This is the highest 
number of any state in the nation. The country still faces many 
challenges in overcoming the pandemic including preparing for 
the upcoming cold and flu season, providing aid to businesses 
in this new coronavirus economy, and helping students navigate 
new learning environments. Experts agree that the virus will 
likely continue to circulate until there is a vaccine. It has 
never been more important to rely on the scientific community 
to guide our decision-making with the best available research 
and data.
    However, over the past few months, we have seen an 
increasing number of attacks against career scientists and 
their work in responding to the pandemic. Most recently, we 
learned that political officials at HHS have routinely 
challenged the science behind the CDC's Morbidity and Mortality 
Weekly Reports, a vital and objective source of COVID-19 data, 
and tried to silence agency officials in order to paint the 
Administration's pandemic response in a better light. Last 
week, Assistant Secretary Michael Caputo even accused CDC 
scientists of ``sedition'' and of organizing a ``resistance 
unit'' against the President. As Members of the Committee on 
Science, Space, and Technology, we do not stand for such 
blatant disregard of scientific integrity in the Federal 
government.
    Our ability to fight the pandemic depends greatly on 
accurate, objective, and accessible data. With it, the Federal 
government can efficiently distribute personal protective 
equipment, testing supplies, and therapeutics. We can better 
understand the spread of the disease and make prudent decisions 
about the economy. Without it, hospitals, patients, and state 
and local jurisdictions can be left in the dark, fighting on 
their own without critical supplies. The American people must 
be able to trust that decisions made at all levels are based on 
trustworthy data and unmarred by political influence.
    We have the world's top scientists doing their best to 
respond to the pandemic. Yet if we allow their work and our 
public health institutions to be influenced by political games, 
we could lose the nation's trust at a critical time. Already, 
many communities of color do not trust the government's role in 
their health. Yet we know-from the CDC's own Morbidity and 
Mortality Weekly Reports, in fact-that these communities have 
been the hardest hit by the pandemic. As we get closer to the 
possibility of a COVID-19 vaccine, we must ensure that the 
Federal government is trustworthy and transparent in its 
decision making.
    Thank you again to our witnesses for testifying today. I 
yield back.

     Chairman Foster. Thank you. And at this time I would like 
to introduce our witnesses.
     Our first witness is Dr. Lisa M. Lee. Dr. Lee is the 
Associate Vice President for Research and Innovation at 
Virginia Tech and holds a faculty appointment in the Department 
of Population Health Sciences. For 30 years, Dr. Lee has worked 
in public health and ethics at the local, State, and Federal 
levels, including 14 years at the CDC. She also served as the 
Executive Director of the Presidential Bioethics Commission and 
most recently as the inaugural Chief of Bioethics at Walter 
Reed Army Institute of Research.
     After Dr. Lee is Dr. Lisa L. Maragakis. Dr. Maragakis is 
an Associate Professor of Medicine and Epidemiology at Johns 
Hopkins University. She is the Senior Director of Infection 
Prevention at the Johns Hopkins Health System and the Hospital 
Epidemiologist for the Johns Hopkins Hospital. Dr. Maragakis 
also serves as the Executive Director of the Johns Hopkins 
Biocontainment Unit as Incident Commander for the Johns Hopkins 
Medicine COVID-19 Response and is the Co-Chair for--of the 
Centers for Disease Control and Prevention's Healthcare 
Infection Control Practices Advisory Committee.
     Our third witness is Mr. Avik Roy, who serves as President 
and Co-Founder of the Foundation for Research on Equal 
Opportunity (FREOPP). He's also the Founder of Roy Healthcare 
Research. Mr. Roy is currently a Senior Advisor to the Working 
Group on Health Care Reform at the Bipartisan Policy Center and 
is a member of the Board of Advisors at the National Institute 
of Health Care Management. His recent writings include papers 
on reopening schools and colleges during COVID-19 and on 
developing strategies for returning people to work during the 
pandemic.
     And our final witness is Mrs. Janet Hamilton--Ms. Janet 
Hamilton. Ms. Hamilton is the Director at the Council for State 
and Territorial Epidemiologists (CSTE). She's also--serves as a 
Board Member of the International Network for Epidemiology and 
Policy and has worked as a consultant on international 
influenza surveillance in Mexico, Ukraine, and Greece. While 
working for the Florida Department of Health's Bureau of 
Epidemiology, she saw surveillance--she oversaw surveillance 
programs for reportable diseases, hospital emergency 
department-based surveillance, outbreaks and natural disaster 
events, antimicrobial resistance, and influenza.
     As our witnesses should know, each of you will have 5 
minutes for your spoken testimony. Your written testimony will 
be included in the record for the hearing. And when you've all 
completed your spoken testimony, we will begin with questions. 
Each member will have 5 minutes to question the panel. And if 
there is time and interest, the Chair may entertain a second 
round of questions.
     And we will start now with Dr. Lee for 5 minutes.

   TESTIMONY OF DR. LISA M. LEE, ASSOCIATE VICE PRESIDENT FOR 
             RESEARCH AND INNOVATION, VIRGINIA TECH

     Dr. Lee. Thank you, Mr. Chairman and Members of the 
Subcommittee, for this opportunity to give voice to the 
critical issue of how the Nation collects, uses, and 
communicates health data during COVID-19 and beyond.
     In my written testimony I addressed three key points in 
response to your questions, and these include, first, that 
public health surveillance is a vital health intelligence 
without which we experience loss of productivity and life; 
second, that public health surveillance is a set of activities, 
all of which must function both during and between public 
health emergencies; and third, that public health surveillance 
requires the public's trust. Without it, the system fails. 
Because of time, I refer you to my written comments, which 
provide a more complete description of my concerns.
     And I'll use this time to highlight my last point: trust. 
Trust is the foundation of all public health practice. It is 
public health's currency. The public has to trust that their 
government leaders are acting in the public's best interest. 
This is especially important for health data, which, along with 
financial data, are the two things people most want to keep 
private. Public health professionals are ethically and legally 
bound to protect identifiable information about individuals for 
whom they provide services.
     Another foundational principle of ethical data collection 
is that data are used for the purpose for which they are 
collected. The public must trust that the data they are being--
that the data--their data are being used to improve health and 
for nothing else, not for profit for a private company, not for 
law enforcement, and not to cause them social, reputational, or 
financial harm. The public must also trust that the conclusions 
drawn from the data that they provide to the system are 
accurate, objective, and will result in benefits to them and 
their community.
     In the case of moving COVID-19 hospital surveillance from 
CDC to the Office of the Secretary at HHS, trust is being 
tested in a number of important ways. First, the removal of 
CDC's public health surveillance experts who together have 
hundreds of combined years of experience in the complex process 
of public health surveillance. Removing them reflects the 
removal of the world's experts in this field. There is no 
equivalent of this expertise in the private sector.
     CDC's surveillance experts work closely with State, local, 
tribal, and territorial health departments to coordinate public 
health surveillance for over 70 conditions. They've established 
a trusted, collaborative relationship with State and local 
partners over many decades. Their surveillance expertise is 
sought after by countries and multilateral health agencies 
across the globe. Removing CDC surveillance scientists from 
this process is like removing trusted NASA (National 
Aeronautics and Space Administration) engineers from sending a 
rocket to Mars.
     Second, the public's trust is challenged by moving data 
collection to an office that is much more vulnerable to 
political pressure from the White House during this most 
volatile and important election year. Moving data collection, 
though data collection alone is not equal to implementing a 
carefully planned, effective public health system. Nonetheless, 
moving the data collection to HHS is seen by many as a move 
that puts the data in great jeopardy not only due to the loss 
of that expertise but also because of lack of objectivity 
driven by political pressure.
     Most Americans--68 percent in a recent poll--do not trust 
what the President says about the pandemic. The number of cases 
and deaths continue to rise with no coordinated Federal 
response insight. The President has suggested that the best way 
to reduce case numbers is to stop testing. Given this and other 
comments, many people find it hard to imagine that there's a 
great deal of support to ensure that COVID-19 data under the 
control of HHS will be complete and well-suited to direct 
public-health action.
     Finally, the data collection contract awarded to a private 
for-profit company raises concerns. The White House has moved 
reporting from CDC to a private entity, but it's abundantly 
clear that public health surveillance is an inherently 
governmental activity. It is a good that creates a number of 
positive externalities and reduces important negative 
externalities. And a good with these characteristics is not 
responsive to what drives markets. When a private company takes 
on an inherently governmental activity like public health 
surveillance, there is a clear mismatch in mission. For-profit 
companies are driven to succeed in order to meet their 
obligation to ensure profits, as they should. But public health 
surveillance is not a profit-driven activity, and this mismatch 
creates a great deal of mistrust.
     The American people have trusted the public health system 
to protect their communities from infectious diseases since 
before we were a country. The foundation of that system, the 
eyes and ears of public health, is public health surveillance. 
And without a well-functioning public health surveillance 
system, we would be unable to meet our fundamental duty to care 
for the health of our Nation. And if we cannot care for the 
health of our Nation, we cannot care for our country's 
prosperity. We cannot afford to fail.
     Thank you, and I look forward to your questions.
     [The prepared statement of Dr. Lee follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
     Chairman Foster. Thank you. And next is Dr. Maragakis for 
5 minutes.

               TESTIMONY OF DR. LISA L. MARAGAKIS,

            SENIOR DIRECTOR OF INFECTION PREVENTION,

                  JOHNS HOPKINS HEALTH SYSTEM

     Dr. Maragakis. Thank you. Good morning, Chairman Foster, 
Ranking Member Norman, and Members of the Committee. Thank you 
for the opportunity to appear before you today to discuss the 
experiences of experts in infection prevention and control 
across the United States who are on the frontlines of the 
pandemic response, leading hospitals and health systems in 
their efforts to accurately and effectively report and utilize 
COVID-19 data.
     I am Dr. Lisa Maragakis. I serve as the Senior Director of 
Infection Prevention for the Johns Hopkins Health System. But 
today in my testimony I am here to represent the members of the 
Society for Healthcare Epidemiology of America, the 
professional society of experts in infection prevention. Our 
members work tirelessly to protect patients by detecting and 
preventing healthcare-associated infections and combating the 
threat of antimicrobial resistance organisms. Having access to 
accurate, timely, and transparent data from a variety of 
sources is vital to our infection prevention work. Accurate 
data helps us to detect infectious disease transmission in 
healthcare, understand the effectiveness of infection 
prevention interventions, and devise innovative solutions to 
prevent infectious disease transmission.
     Our members serve a critical role on the frontlines of the 
COVID-19 pandemic response by collecting, analyzing, and 
utilizing data to inform critical decisions about policies, 
procedures, and hospital resource allocation to keep healthcare 
personnel, patients, and our community safe.
     Healthcare epidemiologists and infection preventionists 
are highly skilled in utilizing data to detect and respond to 
infectious disease threats. Epidemiologists, public health 
officials, and career staff scientists share the common goal of 
wanting to make sure that accurate and timely information sent 
to the right hands at the right time for evidence-based 
strategic decisionmaking.
     For decades, our experts have worked closely with and 
relied upon experts at the Centers for Disease Control and 
Prevention's National Healthcare Safety Network known as NHSN. 
This is a sophisticated data surveillance system that collects, 
analyzes, and reports healthcare-associated infection data. Our 
expert counterparts at the CDC and NHSN are indispensable in 
their expertise and understanding of the nuances and 
intricacies of validating and processing these consequential 
data.
     The NHSN system works very well, and for my colleagues and 
me it seems natural for the CDC to build upon and expand the 
standardized and validated NHSN system to handle the COVID-19 
surveillance data. The NHSN data reporting is largely 
automated, minimizing the burden on healthcare facilities to 
collect and report the data. It therefore was a shock when 
hospitals were abruptly informed in mid-July that they had to 
stop using NHSN for COVID-19 data reporting and instead use the 
TeleTracking system, a new system which was not automated and 
which was unfamiliar. The abrupt transition was made without 
working with hospitals, associations, or the electronic medical 
record vendors to automate the data reporting process.
     Within 48 hours, all healthcare facilities had to scramble 
to manually report the data elements into the new system, find 
new data that had previously not been required, and create new 
workflow processes. This created chaos and confusion and 
diverted critical resources to accomplish the new reporting 
requirements. All of this occurred under a cloud of fear that 
critical Federal support could be withheld if hospitals failed 
to meet these new requirements.
     Although the transition took place several weeks ago, 
chaos persists, and multiple changes to the system continue to 
occur. The data in the new system are not validated by CDC 
experts prior to being used to inform decisions made by the 
Coronavirus Task Force and HHS officials. Data irregularities 
and inconsistencies have been detected in the publicly reported 
data. My colleagues and I have concerns over the accuracy of 
the data that is being used for decisionmaking at the Federal 
and State levels.
     I am here today to share the Society for Healthcare 
Epidemiology of America's colleagues and my experiences and to 
ask for your help to ensure that our country, our hospitals, 
our researchers, and the public have access to accurate, 
timely, and transparent data to help guide our COVID-19 
response.
     Thank you, and I look forward to your questions.
     [The prepared statement of Dr. Maragakis follows:]
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     Chairman Foster. And thank you for that exquisitely timed 
oral presentation.
     The--after Dr. Maragakis is Mr. Roy for 5 minutes.

              TESTIMONY OF MR. AVIK ROY, PRESIDENT,

          FOUNDATION FOR RESEARCH ON EQUAL OPPORTUNITY

     Mr. Roy. Chairman Foster, Mr. Norman, Members of the 
Investigations and Oversight Committee--Subcommittee, it's good 
to see many of you again, and thanks for inviting me here 
today.
     As you mentioned, Mr. Chairman, the Foundation for 
Research on Equal Opportunity or FREOPP for short is a 
nonpartisan think tank that focuses exclusively on ideas that 
can improve the lives of Americans on the bottom half of the 
economic ladder. I welcome the opportunity to discuss how 
better data collection, reporting, and analysis can help all 
Americans weather this pandemic.
     My written statement contains a more detailed discussion 
of this topic, but in my oral remarks, I'm going to focus on 
three subjects. First, I'll discuss how poor data reporting led 
to needless deaths of vulnerable seniors in our nursing homes 
and assisted living facilities. Second, I'll discuss a critical 
flaw in the way that we are reporting and interpreting 
coronavirus PCR (polymerise chain reaction) testing data. 
Third, I'll discuss the value of real-time data aggregation and 
analysis in solving these two problems and also in distributing 
potentially lifesaving medications to severely ill COVID 
patients.
     Many of you are familiar with our research on the tragedy 
taking place in our nursing homes and assisted living 
facilities. Zero-point-six percent of Americans live in long-
term care facilities, and yet within this 0.6 percent of the 
population lies 42 percent of all deaths from the novel 
coronavirus, 42 percent. A major contributor to this problem, 
as Mr. Norman mentioned, has been a lack of consistent data on 
long-term care infections and mortality.
     In the spring, New York and other States ordered nursing 
homes to accept patients being discharged from hospitals with 
active COVID infections. At the time that these orders were 
issued, New York wasn't even collecting data on COVID deaths in 
nursing homes. Today, the State systematically undercounts its 
nursing home deaths in ways that make it harder to protect 
those who remain. CMS (Centers for Medicare & Medicaid 
Services) now requires nursing homes to report COVID fatalities 
directly to them, but if hard-hit States in the spring had 
collected this data in real-time, we could've delivered more 
PPE and testing supplies to long-term care facilities in need.
     A second very large problem was recently identified by 
Apoorva Mandavilli of the New York Times relating to the way in 
which we're administering and reporting PCR test results for 
SARS-CoV-2, the novel coronavirus. PCR is in theory the most 
accurate test that we have for identifying people with active 
viral infections, but as I detail in my written testimony, it 
turns out that many laboratories have been overamplifying PCR 
test samples by a factor of as much as 1,000. The experts 
interviewed by Mandavilli were shocked to learn of this, and 
many said that over half of the positive PCR test results in 
their regions were likely to be false positives based on this 
information.
     This is no mere technical detail because many States and 
school districts are using test positivity rates, case counts, 
and case-based forecasts to determine whether or not to reopen 
schools and their economies. It is essential for PCR lab 
companies to immediately begin including amplification data in 
the form of CT (cycle threshold) values when reporting a 
positive result.
     The good news is that public health officials are 
beginning to gain the capabilities to better analyze nursing 
home data, PCR test results, and many other types of 
information essential to reducing the spread of COVID-19. One 
of these new capabilities is HHS Protect. HHS Protect is 
helping the government reduce--distribute remdesivir, the FDA 
(Food and Drug Administration)-approved drug that has shown 
signs of reducing mortality in hospitalized COVID patients. 
Without detailed real-time information from all U.S. hospitals 
on COVID-19 patients, it wouldn't be possible for authorities 
to distribute limited supplies of remdesivir to patients who 
can most benefit from its use.
     The CDC chose to help build HHS Protect precisely because 
it's traditional decades-old system, the National Healthcare 
Safety Network, would have taken months to be upgraded to the 
same level. Dr. Redfield has been vocal in his--in espousing 
the value of this new system, and I refer you to his remarks 
that I've quoted in my written testimony.
     The transition to HHS Protect has had understandable 
challenges. It's a bit like changing an airplane's engine in 
midflight. And the concerns raised by my colleagues today 
regarding disruption and trust are important ones to address so 
that Americans can have full confidence in the new system. But 
HHS Protect does have significant benefits. It's dynamic 
approach to data aggregation will enable public health 
authorities to analyze detailed PCR testing data so we can 
better understand whether or not patients with very high CT 
values are at risk for illness or transmission. And CDC 
Director Redfield has said that the availability of HHS Protect 
will free up NHSN personnel to apply greater focus on 
protecting vulnerable seniors in nursing homes. As I noted 
earlier, nearly half of all deaths in the United States from 
COVID-19 have taken place in long-term care facilities.
     There's much more to say, let me stop there. I look 
forward to our discussion today. Thank you very much.
     [The prepared statement of Mr. Roy follows:]
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     Chairman Foster. Thank you. And next is Ms. Hamilton for 5 
minutes. And I think you--yes, there's a muting problem 
perhaps.

  TESTIMONY OF MS. JANET HAMILTON, EXECUTIVE DIRECTOR, COUNCIL 
            OF STATE AND TERRITORIAL EPIDEMIOLOGISTS

     Ms. Hamilton. Are you able to hear me now?
     Chairman Foster. OK.
     Ms. Hamilton. OK. Chairman Foster, Ranking Member Norman, 
and Members of the Subcommittee, thank you for the privilege to 
appear before you today. I am Janet Hamilton, Executive 
Director of the Council of State and Territorial 
Epidemiologists. CSTE represents public health epidemiologists 
nationwide working on the front lines to respond to COVID-19.
     Our hearing subject today is one of the most important 
issues we need to tackle as a country. After years of neglect, 
our public health data infrastructure is on crutches, 
antiquated, and in dire need of security upgrades. Sluggish 
paper records, phone calls, spreadsheets, and faxes, requiring 
data entry remain in widespread use and have significant 
consequences: delayed detection and response, lost time, lost 
opportunities, and lost lives.
     COVID-19 has taken advantage of gaps in our current 
system. First, we do not have a seamless interoperable way for 
healthcare to communicate with public health. Our Nation needs 
electronic case reporting. It's that simple. We need to ensure 
that when providers see patients in any setting, patient 
demographics, clinical information, and test results for 
reportable conditions like COVID-19 are rapidly shared with 
State and local public health and then incorporated into CDC's 
National Notifiable Disease Surveillance System.
     Second, we need an electronic lab test ordering process 
that supports the collection of information to launch a rapid 
public health response. The fax machine shouldn't be the 
standard of care. Imagine the time it takes a busy health 
department to sort through thousands of faxed records, 
decipher, and digitize them daily.
     Third, nearly 1/3 of all emergency department visits are 
not reported to the National Syndrome Surveillance System.
     And lastly, death certificates are sometimes filed on 
paper. Deaths surpassing 200,000 tragically tells just part of 
the human cost from COVID-19.
     It takes weeks to uncover and link the death data with 
case, laboratory, and medical examiner data without which we 
cannot understand the racial and ethnic disparities exacerbated 
by COVID-19. The absence of information leaves us blind to the 
truth about the pandemic. State and local public health 
departments indicate initial COVID-19 lab reports are missing 
street address and phone number as much as 50 percent of the 
time. And data for race and ethnicity are missing as much as 85 
percent of the time, despite that these data are already stored 
in electronic health records.
     I have personally felt frustration and anguish and seen my 
colleagues suffer, too, when we want to provide answers to 
community members. Despite wanting to help, we can't because 
our public health data system arteries are clogged. How many 
cases of COVID-19 are there in my area? Where will the next 
hotspot be? When can schools open safely? We can't answer these 
questions without data.
     We have started to implement solutions, but it will take a 
coordinated, sustained approach between State and local public 
health, CDC, Congress, and the Federal Government, as well as 
our healthcare partners. We need to move now. We need to move 
fast. And most importantly, we need to do all of this with 
public health: CDC with their State partners leading.
     CSTE is part of the data elemental to health campaign. 
Before COVID-19, we called on Congress to provide first-ever 
dedicated funding for public health data systems to build a 
21st-century public health data superhighway. As I've outlined 
today, the coordinated systems for this infrastructure already 
exist. We do not have a science problem. We have a resource 
problem. With sustained resources, all jurisdictions could come 
online with the core systems, and CDC could build its own 
secure platform to receive electronic data from States. So far, 
a $550 million down payment has been allocated for the data 
modernization initiative at CDC. This funding is critical, but 
it cannot be a one-off. The Federal Government must commit to 
long-term, annual, base-budget funding to CDC.
     To close, CDC, together with State and local public health 
officials, have led every public health response to date. In 
this response, we have seen inconsistent Federal and State 
coordination. State public health leaders must have direct 
regular access to Federal officials to help contain the virus 
in their regions. We cannot and should not make essential 
policy decisions without CDC and public health experts on the 
ground who fully understand the data-collection challenges and 
strengths.
     Thank you for the opportunity to testify before the 
Subcommittee today.
     [The prepared statement of Ms. Hamilton follows:]
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     Chairman Foster. Thank you. And at this point we will now 
begin our first round of questions, so the Chair will now 
recognize himself for 5 minutes.
     Dr. Lee, we know that surveillance science is more complex 
than simply collecting data and posting it on a website. The 
data often needs to be cleaned and validated for accuracy, and 
anomalous--anomalies must be tracked down, errors corrected. 
Epidemiologists then search for trends and meaning behind the 
raw numbers. They translate their findings into actionable 
advice for decisionmakers. And I'm very concerned that we've 
lost a lot of institutional knowledge by requiring hospitals to 
report critical data to TeleTracking directly instead of 
through the CDC.
     So, Dr. Lee, in your opinion, does HHS have the in-house 
expertise to handle the data collected by TeleTracking and use 
it to make decisions about resource allocations? And perhaps if 
you could also give some examples of the sort of, you know, 
data cleaning and error correction that have to take place.
     Dr. Lee. Thank you, Mr. Chairman, for that great question. 
As I mentioned in my testimony, both written and oral, my--you 
know, I do not think that, you know, there is expertise 
anywhere except at CDC in terms of the complex set of 
activities that it takes to actually develop and implement a 
system. There is expertise, but it's--it lies squarely at CDC. 
As I said, there's hundreds of years of experience there.
     I think the point really is to recognize that developing a 
system that measures sentinel events requires careful thought. 
It requires an understanding of science and epidemiology. It 
requires a sense of what specific data will be needed for 
decisionmaking. So for COVID-19, for example, we've made 
efforts to collect data on a number of events or signals. We 
monitor the number of tests to assess how well we're actually 
measuring the impact of the disease. We use the number of 
proportion of positive tests to measure the current spread of 
infection. We use the number of hospitalizations to say 
something about the number and characteristics of severe cases. 
We also collect data on the number of deaths as an indicator of 
both delayed care and severity of infection but also on the 
effectiveness and equitable distribution of treatment.
     So these kinds of decisions that--about which events to 
include in a surveillance system are critical because they help 
us describe what's happening. And, you know, we have to make 
sure that when we have the data, we are deciding how to 
appropriate and allocate resources to decide when and where to 
deliver public health interventions, so--and also to evaluate 
when these interventions are useful and have helped us to 
combat outbreaks.
     So these important decisions about the design of a system 
should be made by public health surveillance scientists with 
the training and experience in data management, epidemiology, 
statistical analyses and interpretations, as well as a good 
handle on how to communicate risky--risk and--risk data and 
complex data and, you know, data that are not complete--
incomplete data. And since----
     Chairman Foster. Well, thank you. I should--I have to----
     Dr. Lee. Sure.
     Chairman Foster [continuing]. Get into other questions 
here.
     Dr. Lee. OK.
     Chairman Foster. You know, I'm concerned about, you know, 
the way that the TeleTracking requirement was implemented. You 
know, this is--Dr. Maragakis mentioned, it was actually more 
than a fear that payments would be suspended. Secretary Azar 
mentioned--emailed hospitals on April 21st and said please be 
aware that submitting data through TeleTracking is a 
prerequisite to payment, which is not what you want to hear 
when you--you're, you know, trying to deal with an ongoing 
emergency and then you have to divert personnel to learn a 
whole new system and work through its deficiencies.
     And so do you know--you know, can you comment, Dr. 
Maragakis, about some--how hospitals may have been overwhelmed 
and under-resourced, you know, in trying to respond to this 
when that requirement came down?
     Dr. Maragakis. Yes, thank you, Mr. Chairman. It was 
extremely disruptive. The nature of the transition between 
systems really led to what was largely a manual process, 
whereas previously we had automated ways that had been 
constructed to extract the data from electronic medical systems 
and to report these data. As I mentioned in my opening 
testimony, manual processes had to be implemented. Many new 
data elements were required. The reporting frequency was 
escalated to daily. And so this has been a very large burden on 
hospitals and healthcare facilities across the Nation, and many 
are under-resourced to meet that challenge.
     Chairman Foster. Thank you. My time is expired, and I now 
recognize the Ranking Member, Mr. Norman, for five minutes.
     Mr. Norman. Thank you, Chairman Foster.
     Mr. Roy, in your testimony you identified that 42 percent 
of all U.S. deaths from COVID-19 have occurred in long-term 
facilities. Namely, New York City has been publicized as one of 
the worst for the deaths. You go on to explain how some State 
Governors made disastrous decisions to force long-term 
facilities to accept COVID-19-infected patients due to poor 
data on how the virus disproportionately affects the elderly. 
You then indicate that some States are also producing 
misleading data on the number of deaths occurring in these 
facilities. In your opinion, how did we allow inaccurate data 
reporting to occur, and how can we ensure better reporting in 
the future?
     Mr. Roy. Thank you, Mr. Norman. So the big problem here 
was that at the very beginning of the pandemic when we did not 
know very much about SARS-CoV-2, the novel coronavirus, so 
there's obviously a lot we still don't know, but in the 
beginning we knew even less. And a lot of the playbooks that 
the policymakers started using at the State and local levels 
and at the Federal level to some degree were based on influenza 
pandemics. But coronaviruses are not--do not necessarily behave 
in the same way as influenza viruses.
     And so one of the ways in which this played out was the 
biggest concern that you saw, for example, in New York and 
other States like New York that adopted this policy was, well, 
we've got to keep people out of the hospital because we see all 
the pictures from Italy of the hospitals being overwhelmed. 
That's the thing we've got to avoid. We've got to avoid 
hospitals being overwhelmed. And you, nursing homes, are going 
to have to take these patients because all we care about is 
avoiding hospitals being overrun.
     The problem is that in coronavirus pandemics a big problem 
is how lethal SARS-CoV-2 in this case is in vulnerable seniors 
because compared to influenza, SARS-CoV-2 is much more deadly 
in the elderly relative to influenza, which affects the young 
as well to a more significant degree than COVID-19 does. So, as 
a result, they basically forced these infected patients in 
nursing homes and not--weren't even aware of how the nursing 
homes were spreading SARS-CoV-2 and COVID-19 illness. And 
until, again, you know--until it was effectively too late, they 
didn't start pulling that data.
     And to this day, New York State what they do now is they--
if you die in a hospital but you got infected in a nursing 
home, they are counting it as a hospital death, not a nursing 
home death, so we still don't have clear visibility into how 
many people in New York State and New York City have died in 
long-term care facilities. So all this to say these are some of 
the problems early on.
     Now, CMS is starting to require this data to come in 
directly to CMS, and that's helping, but this is an example of 
the way faulty theories and, you know, led to mismanagement, 
and we could've used data to correct those faulty theories and 
we didn't.
     Mr. Norman. Thank you. And, you know, you mentioned that 
Congress has been attempting to upgrade the American public 
health infrastructure for the last decade. What other steps can 
Congress take to modernize sluggish public health data systems 
so that we are better prepared for public health emergencies?
     Mr. Roy. Well, as I mentioned in my written testimony, as 
you know, Mr. Foster, there have been numerous attempts by 
Congress to upgrade public health surveillance infrastructure. 
Until very recently, none of those efforts by Congress, even 
though they were well-funded and had mandates and GAO 
(Government Accountability Office) reports and inspections, led 
to any change in the modernization of that surveillance 
infrastructure. So it's good that we're starting to see that 
difference, and I think it will be very important for Congress 
to deploy its authority to see the difference or the 
improvement if there is an improvement from HHS Protect and 
learn how to use HHS Protect as a more 21st-century approach to 
public health surveillance.
     Mr. Norman. OK. And we're running short on time, but can 
you expand on some of the consequences of overestimating the 
number of positive cases that exist?
     Mr. Roy. Yes. So as I mentioned in my oral and written 
testimony, the--one of the big issues right now is you have a 
number of States that are locking down or closing schools based 
on test positivity rates and cases per 100,000 residents. But 
if a number of those positive test results are based on PCR 
tests, it turns out that in many parts of the country roughly 
half of the positive PCR tests appear to be false positives 
based on this reporting around CT values or the level of 
amplification of the PCR samples that lab companies are using. 
So it's incredibly important that we have a better 
understanding of what's going on in terms of the actual level 
of positivity from a CT value standpoint of these PCR tests. 
That may be part of the reason why--while we're seeing positive 
cases here and in Europe, we're not seeing--or particularly 
here, the same level of deaths per positive case that we saw 
early on in the pandemic. There are other reasons as well, but 
that may be one of them. But most importantly, because of the 
harm from economic restrictions and from school closures, it's 
incredibly important that we are accurately understanding the 
true extent of the spread of the virus.
     Mr. Norman. Great. Thanks so much. I yield back.
     Chairman Foster. Thank you. And I'll now recognize my 
colleague from Oregon, Ms. Bonamici, for 5 minutes.
     Ms. Bonamici. Thank you, Chairman Foster and Ranking 
Member Norman. But thank you to our witnesses. And I know we're 
talking about data today, but I really appreciate the 
acknowledgment that lives are represented by this data. And 
you've articulated why accurate, reliable data and our ability 
to understand and learn from it is so important to save lives 
and protect public health. And now we're at this 200,000-lives-
lost threshold, and each of those individuals was more than a 
statistic, and we have to keep that in mind as we're learning 
today and how are we going to apply the hard lessons over the 
last several months.
     And I want to start with Dr. Maragakis. As you referenced 
in your testimony, HHS made reporting to TeleTracking mandatory 
on July 10 and stated that hospitals had five days to come into 
compliance with this requirement, also announced--HHS also 
announced TeleTracking reporting would now be the sole 
mechanism to calculate distribution of treatment and supplies 
for COVID-19. And I understand this new system included many 
data points that had not previously been requested by CDC, and 
the terminology used in TeleTracking was unclear, leading to 
confusion about what exactly was required.
     So will you please explain the importance of standardized 
data and what it would mean if there are differences in how 
COVID data is compiled and reported? For example, if New York 
City is reporting probable COVID deaths but New York State is 
reporting only confirmed deaths, what does that mean? Describe 
what challenges that might lead to. And I also want to follow 
up on my colleague Mr. Ranking Member Norman's question. If you 
would respond, what is the consequence of underestimating the 
number of positive COVID cases as well?
     Dr. Maragakis. Thank you for the question. As you note, 
standardization of definitions is critical so that when we are 
counting and looking at the data, we are comparing apples to 
apples. That is ideally represented by Federal, national, 
standardized definitions that then can be trickled down through 
the State health departments, and facilities can follow this 
guidance and accomplish accurate reporting so that we are sure 
when we are looking at the numbers that we know precisely what 
is being measured. This is so critical in the case of the 
COVID-19 data.
     And, as you mentioned, the switch from NHSN, which is a 
well-established, validated system with experts that are used 
to measuring these kinds of data elements, it led to poorly 
defined data elements, a lot of confusion, no user manual, 
difficulty getting the answers, and manual reporting of data. 
And so junk in, junk out, unfortunately. If we don't have good 
data and good definitions, we can't rely on what comes out the 
other end.
     Ms. Bonamici. And so all of these issues that you have 
described, have the--all the entities, hospitals and others 
that are reporting to TeleTracking, have they--has HHS been 
responsive to concerns that have been raised? Have they 
responded to feedback in the months since the switch?
     Dr. Maragakis. The implementation of this new system has 
been extraordinarily rocky. It's put an incredible burden on 
hospitals across our Nation. In the earliest days there was no 
guidance. This has gotten slowly better over time, but it has 
been very difficult to get the answers that health systems and 
hospitals need in order to accomplish the reporting.
     Ms. Bonamici. And do you agree that based on all those 
issues and concerns there is a possibility that there could be 
serious consequences from underreporting COVID-19?
     Dr. Maragakis. Absolutely. I feel--and we have to remember 
that this is not just about the cases of COVID-19 but about 
critical data elements that have to do with our response, so 
personal protective equipment on hand, staffing levels, and 
other data elements that are vital to our response and knowing 
how to prepare ourselves and allocate our resources.
     Ms. Bonamici. Thank you. And I wanted to get in a question 
to Ms. Hamilton as well. Thank you for your testimony. You 
raised similar concerns about mismatch and duplicative data in 
your reporting, and we know how important that accurate data 
is. State public health officials are operating under enormous 
strain during the pandemic, as you noted, but if the Federal 
data reporting and management system fails to perform 
competently, the States are forced to react and try to fill 
some of that gap. How are State public health agencies reacting 
to concerns about the lack of validation and transparency for 
data from TeleTracking? And are they taking steps to strengthen 
their own data collection capabilities? And why--what can they 
do to improve short-term data reporting and management at the 
State level? How important it is for them to collaborate on 
subsequent changes?
     Ms. Hamilton. Yes, those are great questions, and changes 
that affect healthcare affect public health because we work in 
such collaboration and coordination. I think the first thing is 
that our guiding principle needs to be to strengthen our public 
health infrastructure and ensure that data flows from 
healthcare to State local public health and then onto the 
Federal Government, so it should be flowing through the public 
health system, not around the public health system.
     And when we saw a change like this, I mean, it was 
confusing. I think you've heard that very well. And it was 
confusing for public health as well. And States have then gone 
and worked very closely with their healthcare providers to 
figure out what kinds of intermediaries can be put in place so 
that the right data is available at the local level for that 
important decisionmaking.
     You know, I also feel like I want to comment on something 
that has come up already, which is funding for public health. 
And I heard a comment that there had been a lot of funding. And 
I really want to make clear that public health has never had 
dedicated funding for surveillance system data modernization 
and improvement. And that's a really critical piece. We need 
that foundational core funding, and it needs to happen on an 
annual basis. There has been----
     Chairman Foster. And I'm afraid I must----
     Ms. Bonamici. The time is expired but----
     Chairman Foster. I must interject----
     Ms. Bonamici [continuing]. Thank you. Thank you, Mr. 
Chairman. Thank you for your----
     Chairman Foster. Thank you.
     Ms. Bonamici [continuing]. Testimony and----
     Chairman Foster. And for Members that are interested, I 
will entertain having a second brief round of questions to 
follow up on anything--issues that have come up.
     I now recognize my colleague from Virginia, Mr. Beyer, for 
5 minutes.
     Mr. Beyer. Mr. Chairman, thank you very much. I really 
appreciate your doing this. And I'm so glad that we're here to 
talk about COVID-19 data and data management and specifically 
about strengthening the public health infrastructure. This has 
really been one of the key weaknesses in the U.S. response.
     I had a conversation with Dr. Chris Murray back in April I 
guess, who is the founder, the leader of the Institute for 
Health Metrics Evaluation, the first website I check every 
morning. And he was so frustrated by the lack of data. And to 
that end we put together the Improving COVID Data Transparency 
Act, which I'm sure that Chairman Foster and Ms. Wexton, and 
Ms. Bonamici are already on.
     I come back to the only computer stuff, GIGO, the garbage 
in, garbage out. If you don't know what you're doing, it's very 
difficult to manage it. Werner Heisenberg, Dr. Foster is our 
only Ph.D. physicist in the Congress, who understands that 
anytime you measure anything, you inevitably change it. And if 
you measure it well, we're going to change it well.
     But let me give you the information framework though 
because we have unfortunately--I don't mean this to be 
political, but this is the reality. We have a President who's 
undermining the role of our Federal institutions. He has a list 
of the intelligence agencies but rather would listen to foreign 
dictators. He undermines the scientific standards at the EPA 
(Environmental Protection Agency) so they can pollute unabated. 
And he undermines the credibility of our health agencies by 
censoring or convoluting the messaging for political reasons.
     Early in the Trump Administration I raised concerns about 
the odd precedent of politicizing basic CMS correspondence to 
the medical community, so Seema Verma then hires image 
consultants. But we didn't imagine that the same narcissism in 
our health system response would hold true during a pandemic 
that placed image over American lives. And we've seen the CDC 
and Dr. Fauci be hamstrung in briefing to the public on the 
epidemic, and we've seen these coronavirus hearings turn into 
functional Trump campaign rallies.
     So responding to this worry, the point of this bill is to 
depoliticized CDC communication. To have noncareer--
nonpolitical rather, nonpolitical career CDC staffers brief the 
public on the Morbidity and Mortality Weekly Reports. These are 
the gold standard, a weekly epidemiology digest published by 
the CDC to share the latest information. And now we understand 
that the Trump officials actually interfere with these reports, 
too.
     So, Dr. Maragakis, what's the danger in this type of 
political review or efforts to intimidate the author's reports 
other than 200,000 American lives?
     Dr. Maragakis. Thank you for your question. You know, we 
are in such a crisis in this country due to the pandemic, and 
there are terrible effects, both health and non-health effects, 
but we all really need to use these data and the guidance from 
the CDC to be able to trust that it is scientifically based, 
that it is evidence-based because we have enough work to do on 
our plates even if we had that clear guidance. And so 
manipulation or confusion or unclear messaging really just 
dilutes the message, it confuses the public, and it makes it 
more difficult for us to take the steps that we need to do to 
prevent viral transmission and to diagnose and care for the 
patients who are afflicted with this disease.
     Mr. Beyer. Thank you very much. Dr. Hamilton, as I 
understand it, only one electronic healthcare record company 
can currently do electronic case reporting immediately to local 
health departments. Can you talk about the benefit of 
electronic case reporting and why that would help us to respond 
faster?
     Ms. Hamilton. Yeah, absolutely. That's a great question. 
And from the public health perspective, when we look at data 
modernization, we feel that this is probably the single biggest 
transformation that we need, and we just have not seen the 
commitment to fund this and invest in it.
     I have some great colleagues across the country that have 
started to implement electronic case reporting. Most 
specifically, I would report from the Florida Department of 
Health, who has recently implemented it. And their comments in 
terms of data improvement from review of the initial data thus 
far is, amazingly, things like missing information is--that gap 
has really been closed, so the address information is missing 
less than 1 percent of the time, phone number as well. I mean, 
these are huge improvements when we look at the ability to 
identify hotspots and contact patients. The race and ethnicity 
information also dramatically improves going down to just 
missing for a few percentage points.
     So, you know, it's the reports that come in, and then that 
allows public health to act in an immediate way to contact the 
patient, to identify contacts rapidly, and then even before you 
can reach someone, you can start aggregating it and identifying 
community-based hotspots, as well as health disparities based 
on that race and ethnicity data.
     Mr. Beyer. That's great, thank you. And, Mr. Chair, I 
yield back with a comment I have a couple of children who are 
form-phobic, but when you do it on the internet it won't let 
you go forward until you put in your address. It really helps.
     Chairman Foster. Thank you. And I will now recognize my 
other colleague from Virginia, Ms. Wexton, for 5 minutes.
     Ms. Wexton. Thank you, Mr. Chairman, and thank you to the 
witnesses for joining us here today.
     You know, following up on the questions of my colleague 
from Virginia, I would ask of all the witnesses, what can we in 
Congress do to protect our public health infrastructure from 
political pressure? Is there anything we can do or are we just 
out of luck?
     Dr. Lee. Well, I'll start by saying that we have to rely 
on evidence, and we have to rely on the experienced public 
health professionals who have been doing public health 
surveillance before we were even a country. In 1741 was the 
first rules around tavernkeepers were, you know, being required 
to report contagious diseases to the colonial leaders. And I 
think the more that we can rely on the expertise and the 
experience of our State, local, and Federal health officials, 
the public health officials and keeping it out of the 
opportunity to spin, to make data, you know, a political pawn 
or a political tool is going to be critically important. And I 
can't agree with you more that what we need is Congress to 
fund--consistently fund public health surveillance and to 
ensure that that--experts who have experience are the ones who 
develop and maintain and implement these systems.
     Ms. Wexton. So through our funding function and our 
oversight function I guess is how we can do it. Thank you, Dr. 
Lee.
     Now, my colleague from Virginia and I, we are very proud 
that our Commonwealth was the first State in August to rollout 
the COVIDWISE app. And people are putting it on their phones. 
I've got it on mine. Don has it on his. And, you know, it's a 
very convenient way to do contact tracing. It'll let you know 
if there--you've been in prolonged contact with a person who 
ultimately tests positive. But in order for it to work, we need 
people to actually have it on their phones. And because it has 
Bluetooth--it operates under Bluetooth technology instead of 
location data, it helps limit some of the privacy concerns that 
a lot of people have. So what can we as public officials do to 
help support our local health departments to get more people to 
put these apps on their phones? Because if we have 150,000 
people who have downloaded it on our phones in Virginia, that's 
great, but in a State with a population of over 8 million, it's 
still just a small proportion of people. So what can we do to 
support those efforts? Dr. Lee, do you have any thoughts on 
that?
     Dr. Lee. Thanks. I do actually. I think Ms. Hamilton will 
have some more State and local perspective, but I think the--as 
I said in my testimony, the primary concern here for folks is 
that the data are being used for the reasons they were 
collected. If people do not trust that that's the case, if they 
think that the data might be used to call ICE (Immigration and 
Customs Enforcement) or to cause some other kind of harm or to 
track their location for other reasons, people will not trust 
the app.
     So we have to make sure that we go back to first 
principles of what ethical data collection is for public 
health, and that means you collect the least amount of data 
necessary, you use them for the purposes for which they were 
collected only, and that you protect the privacy and 
identifiability of the data. Public health has been doing that 
for decades, for centuries, so I think we have a pretty good 
track record.
     Ms. Wexton. Thank you very much. Dr.--Ms. Hamilton, do you 
have anything to add to that?
     Ms. Hamilton. Yes, I mean, I think at the core we need the 
public's trust, and the more that we can support that with 
leadership and recognition that public health has been the 
longest-standing steward of protected health information. We 
have done this since our inception, and we have done it well, 
securely, and safely, and we will continue to do that. And this 
is about people protecting themselves and their families.
     And I think we have to recognize as well that traditional 
contact tracing, because of trust issues right now, is really 
suffering. You know, I hear from State colleagues they're 
identifying one or fewer contacts per case because people are 
not providing that information because of the erosion of trust 
that we have seen. And so we really need voices to lead and 
talk about how much experience public health has in this space 
and how critical it is to use all of the resources that we have 
available to us in order to really halt the spread of this 
virus.
     Ms. Wexton. Thank you very much. And with that I'm going 
to yield back because I see my time is almost up, so thank you 
so much for your responses.
     Chairman Foster. Well, thank you. And I guess there is 
some Member interest in a quick second round of questions, and 
so with that, I will recognize myself for 5 minutes for 
actually a single question.
     You know, there--I--Ms. Hamilton and others have mentioned 
the benefits of automating this in conjunction with the 
electronic health record systems. And one of the big issues in 
any of the automation and cross-operability is the lack in the 
United States of a unique patient identifier. And this is 
something that's been a long-standing problem in our country. 
It was one of the things that enabled the opioid epidemic. The 
fact that there was not a unique patient identifier made it 
impossible to identify a patient who was getting multiple 
opioid prescriptions from multiple doctors in--potentially in 
multiple States.
     And so--and this has been--actually it's Congress' fault. 
There was--25 years ago, my former colleague Ron Paul adopted a 
policy rider, got a policy rider adopted that banned HHS from 
promulgating a unique patient identifier. And so this has been 
killing, by many estimates, tens of thousands of Americans 
every year due to preventable medical errors, due to patient 
misidentification. And of course with the COVID crisis, you 
know, there--additional flaws in a system without a unique 
patient identifier have been made clear, you know, everything 
from getting, you know, uniform death record reportings to just 
combining the healthcare records.
     Zeke Emanuel in his recent study of many different 
countries identified this as a huge problem in the United 
States that isn't present in advanced countries where even in 
countries where there are multiple providers of electronic 
health records, there is a unique identifier so you show up and 
say, OK, here is my patient ID number, and then you can bring 
in the records from many medical providers.
     And so, you know, I am very proud that we're able at least 
in the U.S. House to start fixing this problem. You know, faced 
with this, my Republican partner Representative Kelly and I 
put--got a floor vote last summer, and a strong bipartisan vote 
in favor of repealing that ban and so to finally allow a unique 
patient identifier for patients that wish one.
     And second, we, just a month or two ago, got it adopted 
unanimously in the U.S. House, and so we're now really--this is 
something where the Senate can act by simply concurring with 
the House and save thousands of American lives.
     So I was wondering if you can comment on the importance of 
being able to simply avoid a patient misidentification in this. 
You know, Ms. Hamilton or any one of our panelists.
     Ms. Hamilton. You know, I'll just say that de-duplication 
of records is a huge issue. And, you know, I provided for you 
all as part of my testimony today some of the lab reports that 
health departments currently receive in the thousands, and I 
hope that you'll be able to have those not easily viewable on 
screen, but please do look at some of those handwritten 
reports. I mean, we're deciphering these things, and it does 
create issues and problems. It creates issues identifying the 
right individual, and we get multiple reports on individuals. 
People are tested multiple times. Some of the lab reports only 
include a name and a date of birth with nothing else at all, so 
matching is certainly an issue with important consequence and 
one that we address very carefully within public health to do 
that matching.
     Chairman Foster. Yes, well, I----
     Mr. Roy. Mr. Chairman, I just want to add that I share 
this concern very much, and I'm happy to be helpful to you and 
the Committee in trying to find ways to advance policies that 
would achieve a unique patient identifier.
     Chairman Foster. Yes. It is--I think the ground has 
shifted on that politically on both sides of the aisle 
certainly in the U.S. House. There's just unanimous 
recognition, you know, from the opioid issue if for no other 
reason. And so this is--it's rare that Congress can do 
something that will cost negative money and save thousands of 
lives, but this is certainly an opportunity.
     Anyway, I understand also that Representative Beyer is 
interested in another round of questions, so I'll recognize him 
for 5 minutes.
     Mr. Beyer. Mr. Chairman, thank you very much.
     Following up on our last conversation with Dr. Hamilton, 
one of the things I've been impressed with is 15 years ago I 
learned that when you drive through Taco Bell, if they change 
the price on the--you know, the chalupa by five cents that the 
data immediately goes right to Taco Bell corporate in Atlanta 
or wherever it is, and they are able to figure out what the 
elasticity of demand is based on that. If they can do that at 
fast food restaurants, wouldn't that be nice to be able to do 
that with major health issues? So thank you for pushing forward 
on this.
     I also want to shout out Dr. Maragakis for being part of 
SATA, which is in Arlington, Virginia. You see Virginia leads 
once again. And then Dr. Lee, who was part of Virginia Tech, an 
outright Hokie. So--I know you're upset, but Illinois was once 
part of Virginia back before the--1776, so we include you.
     My bill that we talked about, which I'd love to compare to 
what Ms. Hamilton--Dr. Hamilton has in terms of this national 
infrastructure bill. It tries to restore trust in the CDC but 
also the value of the outsourcing of the modeling because most 
of the current modeling is not being done by the CDC. And a lot 
of the States are hiring expensive outside consulting firms to 
do this.
     So, Dr. Lee, can you talk about the importance of public 
health confidence in the CDC and any concerns about the 
outsourcing of information?
     Dr. Lee. Thank you, excellent question. And I think that, 
you know--I think we've all stated over the last hour and a 
half about the importance of CDC expertise. I think one of the 
things that matters a lot to public health system is that the 
data that we collect and use to address public health issues 
are available not only to experts within CDC but that those 
data become safely available to other very smart people in our 
country who can help us with modeling, who can help with a 
number of different approaches to using the data to best 
prevent infections and, you know, help us mitigate risk for 
this particular infection.
     So I think that, again, I will say that without the 
public's trust in our system to collect the data, we're not 
going to have that for anyone else to use, so we really need to 
be thinking carefully about how we can collect the data that 
is, you know, accurate and valid, how we can safely share those 
data with other really talented researchers in our region, in 
our country, in our world to help us fight this epidemic.
     Ms. Hamilton. Yes. I mean, I just----
     Mr. Beyer. Thank you. We had a Joint Economic Committee 
meeting yesterday with Dr. Ashish Jha, head of the Public 
Health at Brown who was just terrific. And he again emphasized 
that access to information is the single best tool that 
Americans have to protect themselves from the virus.
     Dr. Hamilton, I was impressed that less than one contact 
person is identified in the contact tracing because of fears of 
public trust. Can you tell me, what do they think is going to 
happen? Do they think that the person they identified will be 
arrested in the middle of the night?
     Ms. Hamilton. You know, when we don't reach people, we 
don't know what it is, right? I mean, I think that there's been 
a lot of concerns that are raised when it comes to what and how 
the data could be used. And unfortunately, it's--when it's not 
clear exactly how data is being used and we have confusing, 
mixed messaging, then there are a number of reasons, I'm sure, 
why people no longer want to provide certain kinds of 
information, fear of stigmatization, potential fears for loss 
of work, fears that arise in terms of, you know, will their 
children be able to go back to school. And unfortunately, we've 
seen some really divisive things happen in this pandemic, and I 
think that's why it's so important that we do hold up our 
public health leaders and partners and are clear in terms of 
how the data is being used so that we can really provide that 
information to the public to do our job saving lives.
     Mr. Beyer. That's great. Thank you very much. And, 
Chairman Foster, I yield back.
     Chairman Foster. Well, thank you. And before we bring the 
hearing to a close, I just want to thank our witnesses for 
testifying before the Committee today. I also want to thank you 
personally for your concern about data-quality issues in 
medicine. My daughter Christine does healthcare data analytics 
for the Commonwealth of Massachusetts and regularly complains 
to me about low-quality data and incomplete data that she has 
to wrestle with. And so I think the things you have mentioned 
toward a better path forward in our country, that Congress 
should pay attention to that.
     The record will remain open for 2 weeks for additional 
statements from the Members and any additional questions the 
Committee may ask of the witnesses. The witnesses are now 
excused, and the hearing is now adjourned.
     [Whereupon, at 12:16 p.m., the Subcommittee was 
adjourned.]

                                Appendix

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